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( gֳgֳ     A@  A5% ))     ?1 d0u0@Ty2 NP'p<'pA)BCD|E||0 ž@S"8  g46d6dtb~0lbf ppp@ <4dddd@v8bf\ |)g4BdBdtb~0lb^p@ pp<4!d!d@v8b\ t l ___PPT9N / 0z& , & < @,8D( !OPQU V WXY*Zn:ostwx {F|}@*(B?$ ~Mental Health Services For Older People Country Liaison ServiceO =/+*Shirley Aston CMHN Country Liaison Officer0+6  iROYAL ADELAIDE HOSPITAL Glenside Campus Mental Health Services For Older People Country Liaison Service >Rh8Riverland PresentationIt covers the areas of: The relationship between physical and mental health Staying connected socially Money Matters Medication Depression Dementia Other.6 The Relationship Between Physical and Mental Health 073UThere is evidence that regular exercise helps us to deal with stress. Physical exercise can help to keep a healthy cardiovascular system, This can help to avoid strokes and some types of dementia (vascular). There is evidence that exercise can help recovery from depressive illness. If you can avoid or control many of the illnesses of old age you can also avoid the mental health problems that go with them (some examples are MI and depression, stroke and depression). Avoiding some of the problems associated with the medications needed to control physical illness (side effects and delirium). tFH @ H   L So Does This Mean You All Need to Start Preparation for a Marathon Run? XM'   ( NO --- But Some Sensible Actions Are: ^)   =Getting an annual check up from your GP Identifying and treating health problems promptly Eating a sensible diet Keeping weight down Avoiding excessive alcohol Stop or reduce smoking Moderate and regular aerobic exercise (walk, swim) Exercising joints (Yoga or stretching) Staying relaxed (Tai Chi, Yoga, relaxation) ,==, The Barriers   7What are the barriers to taking some of these actions? .7n7$ ^Cost Motivation Existing disability I m too old00Staying Socially Connected   /Staying Socially Connected,  Evidence suggests that those who have strong and wide social networks do better in terms of mental health. For example, loneliness is a risk factor for depression. Clinical experience suggests that socially isolated people are more prone to anxiety. fk   J Staying Socially Connected & cont. Z&    G Sensible measures Maintaining regular contact with family and friends. Planning retirement so old networks are kept or new ones developed. Negotiating a positive role in family. Using technology to stay in touch and meet new people (phone, internet). Staying active in the community (volunteer work, clubs and associations). 0F33 -Brief Discussion* IWhat opportunities exist in this community to stay socially connected? BHnF  @Church Groups Community Clubs / Associations Government Services 3A  Managing Money 6 ;Financial problems can cause ongoing worries and concerns. <<Managing Money& uPlanning prior to retirement Learning to live in a positive way within your means Preparing your home as low cost and low maintenance Learning to budget Learning to eat well but inexpensively Knowing what you are entitled to and claiming it (many people do not claim benefits they are entitled to) Can you increase your income (some people start new work or small business)*vY. Discussion(    EIs it too late to make any difference once you have already retired? "EF ) Talk it over with a Financial adviser. **  Medication      $Medication & cont.8       Some Facts*   People over 65 constitute 18% of the population but receive 39% of prescribed drugs (i.e. twice as many as younger people). Chronic illness and multiple pathology increase with age, leading to polypharmacy. ||" !S" |Q    Some Facts*   The way drugs act on the body, and the way the body metabolizes and excretes drugs may be altered by age and disease. 1,2 and 3 above increase susceptibility to adverse drug reactions (ADRs). These may include delirium, confusion depression and anxiety. rv" !" v   + The Types of Medication Older People Take *, +Diuretics 25% Analgesics 20% Hypnotics, sedatives and anxiolytics 15% Antirheumatic drugs 15-20% -Blockers 11% Digoxin 6% These are the very medications most likely to cause side effects either singly or in combination. @{c{cSome Problems Encountered* _Duration and review of treatment Prescription errors Comprehension and compliance Concordance``Drugs And The Patient* BAs we age the way medications are absorbed, metabolized and stored may change. This is called: Pharmacokinetics (What the patient s body does to the drug) Also the way the drug acts on the body may also change. This is called: Pharmacodynamics (What the drug does to the patient) OZZ>Z8ZZ8Z`s#Adverse Drug Reactions&   IOften present with non-specific symptoms such as confusion, incontinence, falls. 10% acute geriatric medicine admissions solely or in part due to drug side effects. Drugs commonly associated with ADRs - diuretics, digoxin, antihypertensives, analgesics, non-steroidal anti-inflammatory, anti-Parkinsonian drugs, psychotropics. QTQ T  J Medication Compliance 0Compliance - poor in about 30% of patients. j. " $$Medication Compliance* TPoor motivation - especially if asymptomatic Lack of understanding - complex regime, forgetful, running out of tablets Practical problems - taste, size, 'sticking', vision, dexterity (bottle tops, inhalers) "Intelligent" non-compliance Pills "sticking" I m better now so I ll stop medications $-ZZJZZXZZZZ:ZZ- J X   (  The Role of the Pharmacist(  JOver-the-counter (OTC) medicines taken by about 20% of elderly people Childproof containers are often also elder-proof Typed labels are now mandatory; "as before/as directed/as required" The pharmacist has a vital role in contributing to patient education and in maintaining a 'check' for incorrect dosages, interactions, etc F1DF 1 D  " The Role of the Doctor 8 L Safe and effective prescribing. Maximum benefit with minimum hazard Full diagnosis & consider patient s reaction Start with low doses and adjust cautiously Prescribe known drugs Monitor and record response (or lack of it) Monitor compliance Review drugs regularly Careful drug history"ii  RB,% Role of Care Staff 6 The hand that jogs the doctor s elbow Medications have a role but are not magic bullets Try education life style changes first Help clients to understand what medications are for and side effects Help clients to manage their medications Help clients develop and complete list of their medications what, when, when prescribed, what for, how to take, what to watch out forss Conclusions(    xASK QUESTIONS of the: Doctor Pharmacist Client Carers ENSURE REGULAR REVIEW OF MEDICATION OCCURS CHECK OTC MEDICATIONS|h hhBh  B  0SUMMARYRemain as physically fit as possible Keep in contact with family and friends Maintain financial independence Keep accurate records of all medications taken'Depression In The Elderly (Why Focus On Depression In The Elderly? "()"Depression Definition   t A pervasive and persistent change in mood characterised by depressed mood and loss of interest or pleasure in life.P8t" "s" u #FDepression In The Elderly Is Often Under- diagnosed and Under -treatedGGF ~ This may be because the symptoms are regarded as  normal in this age group. It may be because this group are reluctant to ask for help. It may be that physical illness masks the picture. M<3 M < 3   +FDepression In The Elderly Is Often Under- diagnosed and Under -treatedGGIt may be because depression in older people does not present with the  standard picture. The result is that many elderly suffer needlessly. If detected and treated the elderly have the same response to treatment and have good prospects of recovery. [3m[ 3 m, What Is Depression? 4 Clinical Depression Is Different From Everyday Blues How Long How Pervasive Impact On Life Sadness Loss Of Interest Loss Of Energy Loss Of Appetite And Weight 0- What Is Depression? 4 Sleep Disturbance Inner Feeling Of Restlessness Avoiding Other People Loss Of Confidence Or Self Esteem Feelings Of Being Bad, Worthless Or Guilty Thoughts Of Death And Suicide 01 + How Does a Depressed Person Look and Act? *,(+Poor eye contact Sad face, no smiles, mouth turned down May act as if irritable May look untidy, unshaven not made up Talk and move slowly Cry, call out Ask for help 6!2!*How does a depressed person look and act? ++ Act distressed and fearful Say they want to die, complain or being worthless, helpless, hopeless Say they feel guilty Complain about pain or illness Complain about poor memory or concentration |u K ( Conclusions $      Get an early diagnosis Ensure appropriate treatment is used Seek counselling if required Remember it can be successfully treated Z( A(. A * ODelirium - Definition    A clinical state characterised by an acute, fluctuating change in mental status, with inattention and altered levels of consciousness. F"""  PDelirium - Key Features    <Acute, rapid onset over minutes to days Consciousness is clouded Usually rapid or slow speech Enhanced startle response Disturbed sleep/wake cycle with insomnia Confusion worsens toward evening Nightmares and/or visual hallucinations and/or delusions Symptoms fluctuate over the course of a day or even over minutes 8<" 4< = Q>Delirium - Key Features & cont.v    $  (   [Distressing and unpleasant for the sufferer Frightened, irrational and unpredictable behaviour Awareness of the surrounding environment is reduced Impaired ability to focus, shift or sustain attention Impaired immediate recall and short term memory Disorientation in time, place or person Rapid shifts from under to over activity Slowed reactions T[" ^  $$^  UDelirium - Vulnerability   Most common causes are Medications and Infections. The elderly. Older people post GA. Dementia sufferers. Older persons with : Strokes and Transient Ischaemic attacks Cardiac failure/arrhythmias Anaemia Hypoxia from respiratory failure<" m" m V>Delirium  Vulnerability& cont.8     Uraemia Liver or kidney failure Electrolyte imbalance Acidosis or alkalosis Pre or post epileptic seizure Hypo or hyper Thyroidism Hypo or hyperglycaemia Concussion or sub-dural haematoma following a fall Blood loss T" 4 WDelirium - Management   Diagnosis and treatment of underlying disorders, removal of contributing factors. Behavioural and environmental strategies, and support of the patient and family. Cautious use of medications to minimise challenging behaviours. R" " S" " @" !R"" S"" A&  XDelirium - Alerts   bIs associated with significantly increased resource utilisation, morbidity and mortality. Attempting to manage challenging behaviours with certain medications will lead to a worsening of the delirium. If mistaken for a non reversible dementia then premature placement in a residential care facility may occur. Unresolved delirium can result in death. Z" " o" " m" " )" X o m ) b Y6Delirium  Management Guide  Useful Strategies Include: Simple, but firm communication Adequate lighting Reduction of intense stimulation Unit-wide noise reduction Diurnal variation in noise and lighting Reality orientation " " " 4  k '  ,  ZDDelirium  Management Guide& cont.*#    Presence of a relative Hydration and nutritional support Use of sensory aids Use of single room Maintain activity levels Medication - as a last resort 4"  ! @ $8   nDementia - Definition & $Not a single disease but a syndrome of which there are many causes. The development of multiple cognitive deficits including memory impairment and one or more of the following: Aphasia = loss of the ability to use/understand words. Apraxia = loss of the ability to execute or carry out learned. (familiar) movements. Agnosia = a failure of recognition, visual, auditory or tactile. Disturbance in executive functioning = problem solving, planning skills. " " " Cn""      oDementia - Key Features Decline in memory and other areas of thinking Tendency to over estimate cognitive functioning Decline in social domestic occupational functioning Changes in personality Changes in behaviour>" ."/`"  sDementia - Management Medical referral to diagnose and treat reversible causes Possible referral to specialist for medication (Alzheimer s) Care and education to individual  referral to support services Education and support to family Planning for the future :"  "  tDementia - Alerts kDepression may occur / coexist Safety needs to be considered Psychotic and behavioural issues are common Ri" i" " l w Delusional Disorder - Definition!! "A delusion is a false belief which is inconsistent with the person s sociocultural background and held with absolute and unshakeable conviction. &" x"Delusional Disorder - Key Features## The nature of the disorder ensures that sufferers are quite insightless and cannot be talked out of their peculiar beliefs, which they are often keen to share and may include: Persecutory delusions are most common e.g. Being watched by others Punished or treated badly by others Possessions are being stolen Jealous preoccupation with presumed infidelity of a spouse Grandiose delusions are less common but can occur Convictions that some physical disease or defect is present Are often bound up with the persons home environment^" Z7" Z""6"  {#Delusional Disorder - Vulnerability$$ Female with the following: Socially isolated Have impaired hearing Have had a suspicious, sensitive premorbid personality Dementia sufferers ( Lewy Body) Those with Depression Past history of a psychotic disorder e.g. Schizophrenia Bipolar Affective Disorder " Z_" Z" Za" Z*" Z"_"" _ "  " (   | Delusional Disorder - Management!! Establish differential diagnosis. Treat underlying causes. Maintain safety of client and others - person may act on their delusional beliefs. Rather than confronting the beliefs directly it is preferable to concentrate on the distress experienced by the sufferer. 6" "  }Delusional Disorder - Alerts rPerson may act in a way that is appropriate to their delusional beliefs and can include: self harm harming others making decisions based on delusional beliefs If not correctly diagnosed. then a depressive disorder or dementia may be left untreated. If not correctly diagnosed, the medications selected can lead to a worsening of the situation. e.g. Lewy Body Dementia.Y" ZG" Z" Z" ZY" ""&"" "    s ~SUMMARY0  &Depression - Suspect If :-  A person looks or acts sad Looses interest in activities Complains of loss of energy Expresses suicidal ideas or thoughts of life not being worth living Makes frequent complaints of physical problems with no physical basis*" " Delirium - Suspect If :-  Rapid onset of symptoms, i.e. over hours or days Fluctuating level of consciousness, may vary hour to hour Difficulty in engaging and maintaining the person s attention Disturbed sleepwake cycle Recent history of physical illness, medication changes, trauma J" " Dementia - Suspect If :- $ rLoss of memory, particularly short term memory Confusion Disorientation Change in ADL or Executive functioning /" "  " " " " '" /"" "" "" '"r Delusional Disorders (A belief system which is inconsistent with the person s sociocultural background, (i.e. it seems highly unlikely that the belief is true) and guides and determines behaviour. Is held with absolute and unshakeable conviction, i.e. the person refuses to consider alternative explanations. Delusions may be a feature of Depression or Dementia: In dementia, delusions are most often of theft and suspicion. In Depression, delusions are most often of poverty, guilt, nihilistic ideas that bodily parts are absent, rotting or shrinking. `U" Z" ZZU"" wBDifficult behaviors 0 Medication should not be the first approach Environmental management first Then behavioral management Then is the problem likely to respond to medication Weigh benefits and costs Prescribe low and slow Gauge effects Stop when indicated"DParanoia -- The Word  Paranoia is a term used by mental health specialists to describe suspiciousness (or mistrust) that is either highly exaggerated or not warranted at all.  /X!#(/045t'u(x*z,{-~013456789:;<>?@ACNOPTUVWXYmnrsvw z { |} !$%)*Pbm ` f33` 3f3` ___>?" dd@,|?" dd@   " @ `"  n?" dd@   @@``@n?" dd@  @@``PR    @ ` ` p>>$ ~Mental Health Services For Older People Country Liaison Service ; 3  (  F J  JZ  s *?PP fN +   + Z2  s *?+ U Z2  s *?  Z2  s *?+TZ2  s *?Z2   s *?+UZ2   s *?Z2   s *?+UZ2   s *?Z   s